Clinical outcome and concomitant injuries in operatively treated fractures of the lateral process of the talus

Beyond the imaging evaluation of fractures of the lateral process of the talus: Let's not forget concomitant injuries

Fractures of the lateral process of the talus (FLPT) are uncommon fractures that represent a clinical challenge. Traditional radiological classification systems rely predominantly on radiographic findings. However, due to the high rate of FLPT misdiagnosis and the limited accuracy in evaluating concomitant talar injuries through plain radiographs, novel imaging classification systems have been developed that aim to enhance the diagnosis of concomitant talar injuries, thereby optimizing patient management and reducing the incidence of long-term complications.

Arthroscopic reduction and internal fixation for fracture of the posterior process of the talus (Shepherd's fracture): a case report

INTRODUCTION

Fracture of the lateral tubercle of the posterior process of the talus (Shepherd fracture) is an uncommon injury seen in sport. It is secondary either to indirect trauma on the plantarflexed foot or to high-impact direct trauma. The fracture can be missed with conventional X-rays and therefore advanced imaging methods such as CT scans are usually warranted for management planning. There is a low threshold towards surgical management in the displaced or comminuted case as the delayed functional outcome with conservative treatment is frequently sub-optimal with long-term pain, degenerative changes and non-union. In this regard, recent years saw an increasing interest in the role of minimally invasive approaches for Shepherd´s fracture treatment, such as arthroscopic reduction and internal fixation (ARIF).

CASE REPORT

We present a case of a 27-year-old white male professional football player from Serbia who had Shepard fracture and successfully managed with arthroscopic osteosynthesis. The technical approach is detailed with posterior ankle arthroscopy offering the advantages of a minimally invasive approach with low morbidity and a rapid return to regular sporting activities.

CONCLUSION

The utilization of the 2-port arthroscopic approach this method enables the direct observation of the articular surface along with the corresponding fracture lines, thereby affording the surgeon the chance to achieve accurate reduction via a minimally invasive soft tissue aperture. We advocate that Arthroscopic reduction and internal fixation (ARIF) is a reliable method for the fixation of Shepherd's fracture in the hands of experienced ankle arthroscopists.

Management and classification of the fracture of lateral process of talus: An overview and literature update

Fracture of the lateral process of the talus (FLPT) is uncommon in clinical practice and can be easily missed or misdiagnosed. In recent years, as researchers from all over the world have further deepened their research on FLPT, there has been a breakthrough in the classification, and the methods and principles of clinical management have changed accordingly; however, there is still no standardized guideline for the diagnosis and management of FLPT, and there have been few relevant literature review articles related to this kind of fracture in the past at least 5 years. In this article, we review the clinical classification, classification-based therapeutic recommendations, and prognosis of FLPT, with the aim of providing a reference for the clinical diagnosis and management of this infrequent fracture.

New Classification Based on CT and Its Value Evaluation for Fractures of the Lateral Process of the Talus

This study aimed to develop a comprehensive classification system for fractures of the lateral process of the talus (LPTF) based on CT, and to evaluate its prognostic value, reliability and reproducibility. We retrospectively reviewed 42 patients involving LPTF with an average follow-up of 35.9 months for clinical and radiographic evaluations. In order to develop a comprehensive classification, a panel of experienced orthopedic surgeons discussed the cases. All fractures were classified according to Hawkins, McCrory-Bladin and new proposed classifications by 6 observers. The analysis of interobserver and intraobserver agreements was measured using kappa statistics. The new classification included 2 types based on presence of concomitant injuries or not, with type I consisting of 3 subtypes and type II of 5 subtypes. Average AOFAS score was 91.5 in the type Ia of new classification, 86 in type Ib, 90.5 in type Ic, 89 in type IIa, 76.7 in type IIb, 76.6 in type IIc, 91.3 in type IId, and 83.5 in type IIe. Interobserver and intraobserver reliability of the new classification system were almost perfect (κ = 0.776 and 0.837, respectively), showing a higher interobserver and intraobserver reliability compared to the Hawkins classification (κ 0.572 and 0.649, respectively) as well as McCrory-Bladin classification (κ = 0.582 and 0.685, respectively). The new classification system is a comprehensive one that takes into account concomitant injuries and shows good prognostic value with clinical outcomes. It is more reliable and reproducible and could be a useful tool for decision-making on treatment options for LPTF.

Patient-Reported Outcomes After Lateral Process Talus Fracture

OBJECTIVES

To evaluate functional outcome after lateral process talus fracture using patient-reported instruments and identify injury characteristics that portend a worse prognosis.

DESIGN

Retrospective case series.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Fifty-three patients with isolated lateral process talus fracture and 12 months of minimum follow-up.

MAIN OUTCOME MEASUREMENTS

Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and Foot and Ankle Ability Measure (FAAM).

RESULTS

Mean patient age was 33 years (range, 17-62 years), and mean follow-up was 6.5 years (range, 1-12 years). Twenty-one patients were initially treated nonoperatively and 14 of these patients (67%) failed nonoperative management. Patients who failed nonoperative treatment more commonly had a displaced fracture (12 patients) (P = 0.009). Thirty-two patients had displaced fracture and were treated with early operative fixation. For the entire cohort, final PROMIS PF was 55 (SD -8.3), FAAM Activities of Daily Living (ADL) was 89 (SD -14), and FAAM sport was 77 (SD -20). The patients treated with operative fixation had significantly larger fracture fragments (2050 vs. 1066 mm3, P = 0.017). There was no difference in final outcome between operative and nonoperative patients for PROMIS PF (P = 0.84), FAAM ADL (P = 0.95), or FAAM sport (P = 0.94). There were significantly more subtalar fusions in the nonoperative group (4 patients) as compared to the operative group (one patient) (P = 0.05).

CONCLUSIONS

Most patients with lateral process talus fracture achieve excellent outcome as measured by the PROMIS PF and FAAM at medium-term follow-up. Displaced fractures are likely best managed with early surgical treatment. Patients treated with early surgery have significantly fewer subtalar fusions as compared to patients with nonoperative treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Initial assessment of treatment of talar posterior process fractures with open reduction and percutaneous fixation

The purpose of this study was to provide an initial assessment of treatment for talar posterior process fractures using open reduction and internal fixation (ORIF) through posteromedial approach and percutaneous screw fixation. From January 2014 to December 2018, 12 cases with displaced fracture of talar posterior process were treated in our department. The clinical and radiological results were assessed after 4 and 12 months of operation with Visual Analog Scale (VAS) pain and American Orthopedic Foot and Ankle Society (AOFAS) scores. ORIF was performed in four of the cases and percutaneous screw fixation was performed in eight of the cases. The average follow-up period was 13 months. Complications such as wound infection, nerve injury, screw loosening, malunion or nonunion of fracture were absent. For clinical assessment, considerable mprovements were observed for the AOFAS and VAS scores at 4 and 12 months postoperatively for both techniques. There was no significant difference for AOFAS scores and VAS scores between the two techniques (p > 0.05). Both techniques showed good functional outcome and were performed for posterior talar process fracture following the fracture displacement guidelines. Percutaneous screw fixation treatment with computer-assisted three-dimensional evaluation shortened the operation time and reduced incidences of surgical complications.

The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.